Application for assistance and financial statement

Required *

This is available to the families of doctors who have worked in the Mersey Deanery at some time in their career.

1. Details of medical practitioner who is the applicant or spouse or parent of the applicant

Details of Dependants

Names of children and other household members. Status sholud be : school pupil / student / employed / ill / disabled etc.

2. Medical qualifications.

3. Further details

4. Financial details

Monthly Income
(If a monthly amount cannot be given, provide quarterly (Q) or annual (A) figures in the fields. Amounts given are to be after payment of income tax, if any, has been deducted).

Monthly expenses